An Affiliate of Anne Arundel Dermatology

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For more information about skin conditions and their treatment, contact:


Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C

Stephanie S. Pascale, FNP-C

4201 Lake Boone Trail, #200
Raleigh, NC 27607
Telephone: (919) 782-2152


4201 Lake Boone Trail, #207

Raleigh, NC 27607
Telephone: (919) 863-0073

Female Hormones Plus Stress:
A Formula for Skin Problems

Stress is always a factor in skin disease, notes Dr. Eric Challgren of the Southern Dermatology and Skin Cancer Center in Raleigh. “Stress on top of certain hormone changes and imbalances can be especially problematic for women—causing or exacerbating many dermatological issues.

Dr. Challgren

“For example, stress is often a key factor in hair loss—something that can be particularly distressing for women,” he says. “Although we tend to think of hair loss as a problem associated with men—and we see it more frequently in men—it’s challenging and painful for women, as well. And stress plays a key role.

“If a woman has lost a spouse or a job, has had a major illness, had a baby, or gone through divorce, it’s quite common that three or four months after this emotional upheaval she will experience hair loss. In addition,” he notes, “it’s not uncommon for a woman’s rapidly thinning hair to evoke such a powerful emotional response that the higher stress level itself exacerbates the problem—a difficult Catch-22.

“The most effective cures for these common types of hair loss are the passage of time and reduction of stress,” observes Dr. Challgren. “But, in today’s seemingly relentlessly stressful COVID-19 reality, that may be easier said than done. And while there’s much we don’t know about the new coronavirus and its after-effects, many survivors or ‘long haul’ COVID-19 sufferers have mentioned hair loss as one of its lingering, cruel symptoms.”

Scarring and Non-Scarring Hair Loss

Hair loss conditions called androgenic alopecia or telogen effluvium, along with pseudo-androgenetic alopecia, account for about 95 percent of all hair loss cases in women, explains Dr. Challgren. “In treating women experiencing hair loss,” he says, “we also must distinguish between scarring and non-scarring types.

“Scarring alopecia hair loss is far more challenging, and fortunately far less common,” notes Dr. Challgren, “affecting perhaps as few as three percent of hair loss patients. While there are many forms of scarring alopecia, the common theme is a potentially permanent and irreversible destruction of hair follicles and their replacement with scar tissue.

“Scarring alopecia is particularly difficult to treat, and it’s essential that we discover its underlying cause. And there are many possibilities— including lupus, lichen planopilaris, or central centrifugal alopecia. We do whatever testing needs to be done to determine the cause of the problem.”

Dr. Challgren performs similar detective work with nonscarring pattern hair loss. He evaluates possible iron deficiency, thyroid dysfunction, elevated testosterone levels, and other hormonal imbalances. “Sometimes it’s stress-related telogen effluvium,” he says, “other times it’s an androgenic or pseudo-androgenic alopecia—which is male pattern thinning that women get.

“So it’s not necessarily an easy fix, but there are things we do for women more often than for men. Sometimes it’s hormonal therapy; sometimes we find a high-blood-pressure medication (spironolactone) that has androgen blocking properties is most effective. Topical medications may often be effective, and we are starting to do PRP (platelet rich plasma) injections for some of those patterns. For some, the solution may be hair transplants.”

Other Hormonally-Driven Skin Conditions

Dr. Challgren highlights other differences in dermatological disorders between the sexes. Acne flares, for example, are more commonly seen with males than females in the teen years. But as women age, the situation flips, with more women than men seeking help for chronic acne. “A common complaint a woman will have,” he notes, “is ‘Now I’m 32—why is my acne horrible?!’ Again, the answer is a combination of hormones and stress.”
And hormonal drivers, he points out, can often mean that this becomes more of a chronic disorder to be managed. It also opens other avenues for treatment, like the medication spironolactone, which may help address hormonal acne.

Other conditions affecting women somewhat more commonly than men include rosacea, which is frequently triggered by stress, alcohol, some medications, spicy foods, and too much time in the sun. “Are there hormone issues involved? Quite possibly,” says Dr. Challgren. “For example, several drugs used to regulate the menstrual cycle can cause hot flashes that can trigger or exacerbate rosacea. And women may experience flare-ups during pre-menopause, menopause, and some phases of the menstrual cycle.”
Yet another hormonally driven condition is hirsutism, or hair growth on the face or in other unexpected places. This condition can be symptomatic of a hormonal disorder called polycystic ovarian syndrome, or PCOS.

Dermatoses of Pregnancy

Pregnancy itself—with its dramatic hormonal changes—brings a host challenges for the skin, together known as the dermatoses of pregnancy. Sometimes existing skin conditions worsen but often, new conditions emerge. Prominent among those are pruritic urticarial papules and plaques (PUPPs) and melasma, a hyperpigmentation disorder.

“PUPPs is probably the most common one we see,” notes Dr. Challgren. “Although the itchy bumpy rash is benign, it can cause extreme discomfort. The bumps often go along stretch-mark lines and they are just profusely itchy. You’ll see it towards the end of pregnancy, and it can be pretty miserable for those women.” Although its exact cause isn’t known, it’s believed the rapid stretching of the skin drives the inflammatory reaction underlying it.

Melasma is another hormonally-driven condition generally seen in women, although not exclusively during pregnancy. It can occur with birth control pill use or even with a woman’s own estrogen production, alone or combined with ultraviolet light exposure. “So, for example, a woman, taking birth control pills, will go to the beach for a week and will come back with dark spots on her cheeks or between her eyes,” explains Dr. Challgren. “It’s a hyper-pigmentary disorder, so there are medical treatments for that, including lasers.

“It’s called chloasma when it occurs during pregnancy,” he says, “and is commonly referred to as ‘the mask of pregnancy.’ One of the best treatments is prevention through sun protection, and the problem often improves after delivery—much like PUPPs, which also typically disappears after delivery.”